dr. pavneet kaur selhi · typical intranuclear viral inclusion bearing epithelial cells in the...
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Dr. Pavneet Kaur Selhi Professor, Division of Cytology,
DMC & Hospital, Ludhiana, Punjab INDIA
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Emerging & re-emerging infectious diseases
Threat of bio–terrorism
Ever-growing population of patients with
Iatrogenic
Inherited
Acquired immunodeficiency
Cytopathologist’s perspective
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Conventional LM – poor sensitivity & specificity for detection & identification of
viral infections.
Specific role
Patients with incompletely defined clinical problems
As an adjunct to other diagnostic modalities.
Help in identifying the pattern of ts injury
Advantage
rapid & convenient (bedside)
Sample can cover large areas
SELECTION TAILORED TO CLINICAL SITUATION
Cytopathologist’s perspective
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Cytopathic changes
Inclusion bodies with margination of chromatin on the nuclear membrane
Cowdry type A (herpes)
Cowdry type B (adenovirus or poliovirus)
Multinucleation
Ground glass appearance
Tissue Tropism – organ specific distribution
CMV, HSV, VZV, polyomavirus, Adenovirus – multisystem infection in immunocompromised.
Clues to a viral infection
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Gynecological infection
HPV
HSV CMV
Molluscum contagiosum
Pulmonary infection
Atypical community acquired infections RSV Parainfluenza virus Influenza virus Adenovirus
Immunocompromised CMV HSV/ VZV Measles
EBV
HIV
HSV
CMV
RSV
Adenovirus
Measles
influenza
Viral Lymphadenitis
Tissue Tropism
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62year male
DM /HT /CAD/CKD (ESRD) on HD with CVA
1 episode of GI Bleed
Endoscopy –
Esophagitis with ulcer (?CMV/HSV) with gastric ulcer
Case I
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Case II
S - 26F , Tzanck smear
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Case III
32 year old female – PAP Smear
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HSV- 1 & 2
Pap smears
GIT
Respiratory specimens (Immunocompromised patients)
HSV-1 Respiratory tract.
HSV-2 Sexual activity
Conspicuous nuclear changes - Infected cells
PAP stain - most desirable
Herpes simplex virus
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Multinucleation – Cowdry type A (“eggs in a basket”)
(Acta Cytol 1994;38:43)
Moulding Margination
Mononucleated cells – Early disease (DeMay: The Pap Test: Exfoliative Gynecologic Cytology; 2005)
Confirmation – culture , ICC , IF , and ISH techniques
Three M’s of Herpes
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CASE IV
PAP Smear for screening
Large defined perinuclear halos, binucleation, and slight nuclear atypia, with smudged chromatin.
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Koilocytes – “Koilos” (hollow or cavity)
Recognition is based on:
marked density of the cytoplasm peripheral to the cavity,
amphophilic cytoplasm, and
enlarged hyperchromatic nucleus.
Other features:
bi- and multinucleation,
plaques or aggregates of parakeratosis and hyperkeratosis,
anucleate squames
HPV
.
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The 2014 Bethesda System
Squamous Epithelial Cell Abnormalities
Dichotomous reporting terminology for LSIL and HSIL is maintained
Natural history of HPV-related infections –
low-grade changes represent productive, largely transient HPV infection
high-grade morphology represents a precancerous lesion.
The Pap Test and Bethesda 2014 - Acta Cytologica 2015;59:121-132
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CASE V
• Solitary cells. • enlarged nuclei with nuclear inclusions
• almost fill the nucleus • thin rims or halos. Urine sample in Renal allograft Recipient
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Typical intranuclear viral inclusion bearing epithelial cells in the urine.
Different morphologic variants (types 1 through 4)
Easily identified and quantifiable in
routine Papanicolaou stained urine cytology specimens.
unstained urinary sediment by phase contrast microscopy.
Ancillary techniques - IHC, EM, and FISH.
Decoy cells
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Parameter to assess the risk for disease in RAR – BKN
Sensitivity and specificity of decoy cells for diagnosing BKN is 99% and 95%, respectively
PPV varies between 27% to 90%
NPV is 99%.
Detection of decoy cells – comparable to PCR and EM (assess the activation of polyomaviruses in the urine).
Decoy cells .
Polyomaviruses and Human Diseases - Advances in Experimental Medicine and Biology, Volume 577 , pp 201-212
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HSV/VZV– Cowdry type A and B inclusions in Metaplastic squamous cells & Multinucleated giant cells CMV – Large intranuclear and small cytoplasmic inclusions, multinucleation rare Adenovirus - Intranuclear inclusions (smudge cells) and ciliocytophthoria. Respiratory syncytial virus—syncytial giant cells. Parainfluenza—syncytial giant cells with cytoplasmic inclusions and ciliocytophthoria. Measles - multinucleated giant cells with cytoplasmic and intranuclear Cowdry type A inclusions.
PULMONARY VIRAL INFECTIONS
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Viral lymphadenitis – Cytological clues
VIRUS CYTOLOGICAL FEATURES
EBV - Infectious mononucleosis Immunoblasts with atypia
HIV Polymorphous lymphoid cell pattern , plasma cells, Opportunistic infections.
HSV 3 M’s
CMV Large cells – Owl’s eye inclusion.
VZV Rare intranuclear inclusion
Measles Polykaryocytes
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Ophthalmic viruses
Superficial viral eye diseases
21 of 38 patients with suspected HSV
3 of 4 patients with suspected VZV
2 of 10 patients with suspected Adenovirus infection.
Clinical evaluation of impression cytology in diagnosis of superficial viral infections Klin Monbl Augenheilkd. 1998 May;212(5):388-91
Improved impression cytology techniques for the immunopathological diagnosis of superficial viral infections Br J Ophthalmol. 1997 Nov; 81(11): 984–988